251
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Bral M, Gala-Lopez B, Bigam DL, Freed DH, Shapiro AMJ. Ex situ liver perfusion: Organ preservation into the future. Transplant Rev (Orlando) 2018; 32:132-141. [PMID: 29691119 DOI: 10.1016/j.trre.2018.03.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 03/27/2018] [Accepted: 03/27/2018] [Indexed: 12/15/2022]
Abstract
In recent years, remarkable progress has occurred in the development of technologies to support ex situ liver perfusion. Building upon extensive preclinical studies in large animal models, pilot and randomized clinical trials have been initiated, and preliminary outcomes suggest more optimal protection of both standard and extended criteria liver grafts. There currently exists an incredible opportunity and need to further refine this technology, determine appropriate viability measures to predict usable liver grafts, and to explore potent protective additive strategies to further optimize the quality of extended criteria organs. These findings will have major bearing in expanding the limited liver donor pool, and may save lives where up to a quarter of listed patients die on wait-lists. Herein we offer a brief overview of the history and current status of ex situ liver perfusion, and discuss future directions that will likely have major impact on the practice of clinical liver transplantation.
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Affiliation(s)
- Mariusz Bral
- Department of Surgery, University of Alberta, 2D4.43 Walter D MacKenzie Health Sciences Centre, 8440 112 St, Edmonton, Alberta T6G2B7, Canada; Members of the Canadian National Transplant Research Program (CNTRP), 2D4.43 Walter D MacKenzie Health Sciences Centre, 8440 112 St, Edmonton, Alberta T6G2B7, Canada.
| | - Boris Gala-Lopez
- Department of Surgery, University of Alberta, 2D4.43 Walter D MacKenzie Health Sciences Centre, 8440 112 St, Edmonton, Alberta T6G2B7, Canada; Members of the Canadian National Transplant Research Program (CNTRP), 2D4.43 Walter D MacKenzie Health Sciences Centre, 8440 112 St, Edmonton, Alberta T6G2B7, Canada.
| | - David L Bigam
- Department of Surgery, University of Alberta, 2D4.43 Walter D MacKenzie Health Sciences Centre, 8440 112 St, Edmonton, Alberta T6G2B7, Canada; Members of the Canadian National Transplant Research Program (CNTRP), 2D4.43 Walter D MacKenzie Health Sciences Centre, 8440 112 St, Edmonton, Alberta T6G2B7, Canada.
| | - Darren H Freed
- Department of Surgery, University of Alberta, 2D4.43 Walter D MacKenzie Health Sciences Centre, 8440 112 St, Edmonton, Alberta T6G2B7, Canada; Members of the Canadian National Transplant Research Program (CNTRP), 2D4.43 Walter D MacKenzie Health Sciences Centre, 8440 112 St, Edmonton, Alberta T6G2B7, Canada.
| | - A M James Shapiro
- Department of Surgery, University of Alberta, 2D4.43 Walter D MacKenzie Health Sciences Centre, 8440 112 St, Edmonton, Alberta T6G2B7, Canada; Members of the Canadian National Transplant Research Program (CNTRP), 2D4.43 Walter D MacKenzie Health Sciences Centre, 8440 112 St, Edmonton, Alberta T6G2B7, Canada.
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252
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Normothermic Ex Vivo Machine Perfusion for Liver Grafts Recovered from Donors after Circulatory Death: A Systematic Review and Meta-Analysis. HPB SURGERY : A WORLD JOURNAL OF HEPATIC, PANCREATIC AND BILIARY SURGERY 2018; 2018:6867986. [PMID: 29849531 PMCID: PMC5937385 DOI: 10.1155/2018/6867986] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 03/15/2018] [Indexed: 12/20/2022]
Abstract
As a result of donation after circulatory death liver grafts' poor tolerance to cold storage, there has been increasing research interest in normothermic machine perfusion. This study aims to systematically review the current literature comparing normothermic perfusion to cold storage in donation after circulatory death liver grafts and complete a meta-analysis of published large animal and human studies. A total of nine porcine studies comparing cold storage to normothermic machine perfusion for donation after circulatory death grafts were included for analysis. There was a significant reduction in AST (mean difference −2291 U/L, CI (−3019, −1563); P ≤ 0.00001) and ALT (mean difference −175 U/L, CI (−266, −85); P = 0.0001), for normothermic perfusion relative to static cold storage, with moderate (I2 = 61%) and high (I2 = 96%) heterogeneity, respectively. Total bile production was also significantly higher (mean difference = 174 ml, CI (155, 193); P ≤ 0.00001). Further research focusing on standardization, performance of this technology following periods of cold storage, economic implications, and clinical trial data focused on donation after circulatory death grafts will be helpful to advance this technology toward routine clinical utilization for these grafts.
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253
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Zhao Q, Huang S, Wang D, Zhang Z, Wu L, Yang L, Ma Y, Ji F, Tang Y, Wang L, Zhu Z, Zhu Y, Xiong W, Chen M, Han M, Zhou J, Hu A, Wang G, Jiao X, Zhu X, Ju W, Guo Z, He X. Does Ischemia Free Liver Procurement Under Normothermic Perfusion Benefit the Outcome of Liver Transplantation? Ann Transplant 2018. [PMID: 29674604 PMCID: PMC6248288 DOI: 10.12659/aot.909645] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background In contrast to conventional static cold preservation, normothermic machine perfusion (NMP) provides a beneficial alternative preservation of donor livers. However, the liver still suffered cold ischemic injury before attaching to the perfusion device. Material/Methods To prevent cold ischemic injury during procurement, we describe a novel procedure called ischemia-free liver procurement (IFLP) under NMP. Two liver grafts were procured from brain death donor under NMP and underwent 2-hour ex vivo NMP followed by 3 and 6 hours of static cold preservation. From procurement to post-transplantation course, evidence was collected to prove that IFLP is safe and benefits recipients. Results The post-transplantation course was uneventful, and the liver function tests and histological study revealed minimal hepatocyte and biliary epithelium injury during the preservation. Conclusions This preliminary experience demonstrates the clinical feasibility and safety of IFLP under NMP which offering opportunities to increase the number of donor livers and to improve the organ function.
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Affiliation(s)
- Qiang Zhao
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, China (mainland)
| | - Shanzhou Huang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, China (mainland)
| | - Dongping Wang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, China (mainland)
| | - Zhiheng Zhang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, China (mainland)
| | - Linwei Wu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, China (mainland)
| | - Lu Yang
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland)
| | - Yi Ma
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, China (mainland)
| | - Fei Ji
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, China (mainland)
| | - Yunhua Tang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, China (mainland)
| | - Linhe Wang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, China (mainland)
| | - Zebin Zhu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, China (mainland)
| | - Yanling Zhu
- Department of Cardiopulmonary Bypass, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland)
| | - Wei Xiong
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland)
| | - Maogen Chen
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, China (mainland)
| | - Ming Han
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, China (mainland)
| | - Jian Zhou
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, China (mainland)
| | - Anbin Hu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, China (mainland)
| | - Guodong Wang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, China (mainland)
| | - Xingyuan Jiao
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, China (mainland)
| | - Xiaofeng Zhu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, China (mainland)
| | - Weiqiang Ju
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, China (mainland)
| | - Zhiyong Guo
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, China (mainland)
| | - Xiaoshun He
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, China (mainland)
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254
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DCD Liver Transplant: a Meta-review of the Evidence and Current Optimization Strategies. CURRENT TRANSPLANTATION REPORTS 2018. [DOI: 10.1007/s40472-018-0193-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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255
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A randomized trial of normothermic preservation in liver transplantation. Nature 2018; 557:50-56. [DOI: 10.1038/s41586-018-0047-9] [Citation(s) in RCA: 578] [Impact Index Per Article: 96.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 03/08/2018] [Indexed: 02/07/2023]
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256
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257
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Matton APM, Burlage LC, van Rijn R, de Vries Y, Karangwa SA, Nijsten MW, Gouw ASH, Wiersema‐Buist J, Adelmeijer J, Westerkamp AC, Lisman T, Porte RJ. Normothermic machine perfusion of donor livers without the need for human blood products. Liver Transpl 2018; 24:528-538. [PMID: 29281862 PMCID: PMC5900573 DOI: 10.1002/lt.25005] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Revised: 11/28/2017] [Accepted: 12/18/2017] [Indexed: 12/23/2022]
Abstract
Normothermic machine perfusion (NMP) enables viability assessment of donor livers prior to transplantation. NMP is frequently performed by using human blood products including red blood cells (RBCs) and fresh frozen plasma (FFP). Our aim was to examine the efficacy of a novel machine perfusion solution based on polymerized bovine hemoglobin-based oxygen carrier (HBOC)-201. Twenty-four livers declined for transplantation were transported by using static cold storage. Upon arrival, livers underwent NMP for 6 hours using pressure-controlled portal and arterial perfusion. A total of 12 livers were perfused using a solution based on RBCs and FFPs (historical cohort), 6 livers with HBOC-201 and FFPs, and another 6 livers with HBOC-201 and gelofusine, a gelatin-based colloid solution. Compared with RBC + FFP perfused livers, livers perfused with HBOC-201 had significantly higher hepatic adenosine triphosphate content, cumulative bile production, and portal and arterial flows. Biliary secretion of bicarbonate, bilirubin, bile salts, and phospholipids was similar in all 3 groups. The alanine aminotransferase concentration in perfusate was lower in the HBOC-201-perfused groups. In conclusion, NMP of human donor livers can be performed effectively using HBOC-201 and gelofusine, eliminating the need for human blood products. Perfusing livers with HBOC-201 is at least similar to perfusion with RBCs and FFP. Some of the biomarkers of liver function and injury even suggest a possible superiority of an HBOC-201-based perfusion solution and opens a perspective for further optimization of machine perfusion techniques. Liver Transplantation 24 528-538 2018 AASLD.
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Affiliation(s)
- Alix P. M. Matton
- Surgical Research LaboratoryUniversity of Groningen, University Medical Center GroningenGroningenthe Netherlands,Section of Hepatobiliary Surgery and Liver Transplantation, Departments of SurgeryUniversity of Groningen, University Medical Center GroningenGroningenthe Netherlands
| | - Laura C. Burlage
- Surgical Research LaboratoryUniversity of Groningen, University Medical Center GroningenGroningenthe Netherlands,Section of Hepatobiliary Surgery and Liver Transplantation, Departments of SurgeryUniversity of Groningen, University Medical Center GroningenGroningenthe Netherlands
| | - Rianne van Rijn
- Surgical Research LaboratoryUniversity of Groningen, University Medical Center GroningenGroningenthe Netherlands,Section of Hepatobiliary Surgery and Liver Transplantation, Departments of SurgeryUniversity of Groningen, University Medical Center GroningenGroningenthe Netherlands
| | - Yvonne de Vries
- Surgical Research LaboratoryUniversity of Groningen, University Medical Center GroningenGroningenthe Netherlands,Section of Hepatobiliary Surgery and Liver Transplantation, Departments of SurgeryUniversity of Groningen, University Medical Center GroningenGroningenthe Netherlands
| | - Shanice A. Karangwa
- Surgical Research LaboratoryUniversity of Groningen, University Medical Center GroningenGroningenthe Netherlands,Section of Hepatobiliary Surgery and Liver Transplantation, Departments of SurgeryUniversity of Groningen, University Medical Center GroningenGroningenthe Netherlands
| | - Maarten W. Nijsten
- Department of Critical CareUniversity of Groningen, University Medical Center GroningenGroningenthe Netherlands
| | - Annette S. H. Gouw
- Department of Pathology, University of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Janneke Wiersema‐Buist
- Surgical Research LaboratoryUniversity of Groningen, University Medical Center GroningenGroningenthe Netherlands
| | - Jelle Adelmeijer
- Surgical Research LaboratoryUniversity of Groningen, University Medical Center GroningenGroningenthe Netherlands
| | - Andrie C. Westerkamp
- Surgical Research LaboratoryUniversity of Groningen, University Medical Center GroningenGroningenthe Netherlands,Section of Hepatobiliary Surgery and Liver Transplantation, Departments of SurgeryUniversity of Groningen, University Medical Center GroningenGroningenthe Netherlands
| | - Ton Lisman
- Surgical Research LaboratoryUniversity of Groningen, University Medical Center GroningenGroningenthe Netherlands
| | - Robert J. Porte
- Section of Hepatobiliary Surgery and Liver Transplantation, Departments of SurgeryUniversity of Groningen, University Medical Center GroningenGroningenthe Netherlands
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258
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Vasodilation During Normothermic Machine Perfusion; Preventing the No-Reflow Phenomena. Transplantation 2018; 102:548-549. [DOI: 10.1097/tp.0000000000002072] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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259
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Pushing the Limits: Machine Preservation of the Liver as a Tool to Recondition High-Risk Grafts. CURRENT TRANSPLANTATION REPORTS 2018; 5:113-120. [PMID: 29774176 PMCID: PMC5945712 DOI: 10.1007/s40472-018-0188-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Purpose of the Review Machine perfusion (MP) is a novel technology recently introduced in liver transplantation, redefining the current practice of organ preservation and pushing the limits of high-risk liver utilisation. This review highlights the key benefits of machine perfusion over conventional static cold storage (SCS), demonstrated in human liver research and clinical transplants. Recent Findings The first clinical trials have demonstrated both safety and feasibility of MP. The most recent transplant series and result from a randomised trial suggest the technology is superior to SCS. The key benefits include extended period of organ preservation, decreased incidence of early allograft dysfunction and reduction of biliary complications. Normothermic liver perfusion allows viability testing to guide transplantability of the highest-risk organs. This technology also provides opportunities for therapeutic interventions to improve liver function and quality in organs that are currently declined for clinical use. Summary Machine perfusion is likely to transform the liver preservation pathway and to improve utilisation of high-risk grafts.
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260
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Angelico R, Perera MTPR, Manzia TM, Parente A, Grimaldi C, Spada M. Donation after Circulatory Death in Paediatric Liver Transplantation: Current Status and Future Perspectives in the Machine Perfusion Era. BIOMED RESEARCH INTERNATIONAL 2018; 2018:1756069. [PMID: 29744353 PMCID: PMC5878911 DOI: 10.1155/2018/1756069] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 02/14/2018] [Indexed: 02/06/2023]
Abstract
Efforts have been made by the transplant community to expand the deceased donor pool in paediatric liver transplantation (LT). The growing experience on donation after circulatory death (DCD) for adult LT has encouraged its use also in children, albeit in selective cases, opening new perspectives for paediatric patients. Even though there has recently been a slight increase in the number of DCD livers transplanted in children, with satisfactory graft and patient outcomes, the use of DCD grafts in paediatric recipients is still controversial due to morbid outcomes associated with DCD grafts. In this context, recent advances in the optimization of donor support by extracorporeal membrane oxygenation and in the graft preservation by liver machine perfusion could find application in order to expand the donor pool in paediatric LT. In the present study we review the current literature on DCD liver grafts transplanted in children and on the use of extracorporeal donor support and liver perfusion machines in paediatrics, with the aim of defining the current status and future perspectives of paediatric LT.
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Affiliation(s)
- Roberta Angelico
- Division of Abdominal Transplantation and Hepatobiliopancreatic Surgery, Bambino Gesù Children's Research Hospital IRCCS, Rome, Italy
| | | | - Tommaso Maria Manzia
- Department of Experimental Medicine and Surgery, Liver Unit, Tor Vergata University of Rome, Rome, Italy
| | - Alessandro Parente
- Department of Experimental Medicine and Surgery, Liver Unit, Tor Vergata University of Rome, Rome, Italy
| | - Chiara Grimaldi
- Division of Abdominal Transplantation and Hepatobiliopancreatic Surgery, Bambino Gesù Children's Research Hospital IRCCS, Rome, Italy
| | - Marco Spada
- Division of Abdominal Transplantation and Hepatobiliopancreatic Surgery, Bambino Gesù Children's Research Hospital IRCCS, Rome, Italy
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261
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Obara H, Morito N, Matsuno N, Yoshikawa R, Gouchi M, Otani M, Shonaka T, Takahashi H, Enosawa S, Hirano T, Furukawa H. Optimum Perfusate Volume of Purified Subnormothermic Machine Perfusion for Porcine Liver Donated After Cardiac Death. Transplant Proc 2018; 50:2830-2833. [PMID: 30401406 DOI: 10.1016/j.transproceed.2018.03.055] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Accepted: 03/02/2018] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Subnormothermic machine perfusion (SNMP) shows some advantages for the preservation of grafts donated after cardiac death (DCD) and improvements in machine perfusion (MP) technology are important to enhance organ preservation outcomes for liver transplantation. In this study, we focused on purified subnormothermic machine perfusion (PSNMP) and volumes of perfusate removed to substitute for purification and replaced by modified University of Wisconsin-gluconate after the start of perfusion and investigated, in particular, the optimum perfusate purification volume. Several purification volumes under SNMP were compared. In addition, the perfusate purification during MP was indicated as a potential technique to enhance the organ quality of DCD grafts and extended-criteria donors. METHODS The PSNMP at several volumes (0.5 L, 1.5 L, and 3 L) were compared with regular SNMP without any purification treatment (untreated control). In the PSNMP group, all perfusate was removed to substitute for purification of the perfusate by modified University of Wisconsin-gluconate solution after the start of perfusion. After removing the perfusate, new perfusate with the same components was perfused to preserve the porcine livers obtained under warm ischemia for 60 minutes using SNMP at 22°C porcine liver for 4 hours. RESULTS The concentrations of aspartate aminotransferase and lactate dehydrogenase in the untreated group were significantly higher during perfusion compared to those of the intervention group. There are no significant differences among the volume conditions of the purification groups. CONCLUSIONS The optimal volume of perfusate purification was confirmed with a simple experimental comparison between untreated and PSNMP conditions.
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Affiliation(s)
- H Obara
- Department of Mechanical Engineering, Tokyo Metropolitan University, Tokyo, Japan; National Center for Child Health and Development, Tokyo, Japan.
| | - N Morito
- Department of Mechanical Engineering, Tokyo Metropolitan University, Tokyo, Japan
| | - N Matsuno
- Department of Mechanical Engineering, Tokyo Metropolitan University, Tokyo, Japan; National Center for Child Health and Development, Tokyo, Japan; Department of Surgery, Asahikawa Medical University, Hokkaido, Japan
| | - R Yoshikawa
- Department of Mechanical Engineering, Tokyo Metropolitan University, Tokyo, Japan
| | - M Gouchi
- Department of Surgery, Asahikawa Medical University, Hokkaido, Japan
| | - M Otani
- Department of Surgery, Asahikawa Medical University, Hokkaido, Japan
| | - T Shonaka
- Department of Surgery, Asahikawa Medical University, Hokkaido, Japan
| | - H Takahashi
- Department of Surgery, Asahikawa Medical University, Hokkaido, Japan
| | - S Enosawa
- National Center for Child Health and Development, Tokyo, Japan
| | - T Hirano
- Department of Clinical Pharmacology, Tokyo University of Pharmacy and Life Sciences, Tokyo, Japan
| | - H Furukawa
- Department of Surgery, Asahikawa Medical University, Hokkaido, Japan
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262
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Schlegel A, Scalera I, Perera MTPR, Kalisvaart M, Mergental H, Mirza DF, Isaac J, Muiesan P. Impact of donor age in donation after circulatory death liver transplantation: Is the cutoff "60" still of relevance? Liver Transpl 2018; 24:352-362. [PMID: 28885771 DOI: 10.1002/lt.24865] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 06/19/2017] [Accepted: 08/24/2017] [Indexed: 02/07/2023]
Abstract
Advanced donor age has been identified as a risk factor when combined with donor warm ischemia time (WIT), eg, in donation after circulatory death (DCD). In several countries, DCD livers older than 60 years are not considered suitable due to concerns related to poor graft function and development of ischemic cholangiopathy. In this study, we evaluate outcomes after DCD liver transplantation using grafts from donors older than 60 years. We analyzed outcomes after DCD liver transplantation (n = 315), comparing donors > 60 years (n = 93) and donors ≤ 60 years (n = 222) from our center between 2005 and 2015. End points included graft function and complications and patient and graft survival. Multivariate risk analysis was performed to define further key factors that predicted inferior outcome. Donor age at the cutoff 60 years failed to stratify patient and graft survival. The rate of vascular, biliary, and overall complications was comparably low in both cohorts, and the median comprehensive complication index was 42.7 points, independent from the donor age. Second, donor body mass index (BMI) above a threshold of 25 kg/m2 significantly impacted on graft and patient survival at any donor age, whereas donor WIT and cold ischemia times were not predictive for graft loss. In conclusion, older DCD donors can be successfully used for liver transplantation with good longterm outcomes when further risk factors are limited. Additional risk is transmitted by an increased donor BMI regardless of donor age. Liver Transplantation 24 352-362 2018 AASLD.
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Affiliation(s)
- Andrea Schlegel
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK.,National Institute for Health Research Liver Biomedical Research Unit, University Hospitals Birmingham, Birmingham, UK
| | - Irene Scalera
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK
| | - M Thamara P R Perera
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK.,National Institute for Health Research Liver Biomedical Research Unit, University Hospitals Birmingham, Birmingham, UK.,Department of Liver Surgery, Birmingham Children's Hospital National Health Service Foundation Trust, Birmingham, UK
| | - Marit Kalisvaart
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK
| | - Hynek Mergental
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK.,National Institute for Health Research Liver Biomedical Research Unit, University Hospitals Birmingham, Birmingham, UK
| | - Darius F Mirza
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK.,National Institute for Health Research Liver Biomedical Research Unit, University Hospitals Birmingham, Birmingham, UK.,Department of Liver Surgery, Birmingham Children's Hospital National Health Service Foundation Trust, Birmingham, UK
| | - John Isaac
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK.,Department of Liver Surgery, Birmingham Children's Hospital National Health Service Foundation Trust, Birmingham, UK
| | - Paolo Muiesan
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK.,Department of Liver Surgery, Birmingham Children's Hospital National Health Service Foundation Trust, Birmingham, UK
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263
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Kaths JM, Hamar M, Echeverri J, Linares I, Urbanellis P, Cen JY, Ganesh S, Dingwell LS, Yip P, John R, Bagli D, Mucsi I, Ghanekar A, Grant D, Robinson LA, Selzner M. Normothermic ex vivo kidney perfusion for graft quality assessment prior to transplantation. Am J Transplant 2018; 18:580-589. [PMID: 28889600 DOI: 10.1111/ajt.14491] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 07/20/2017] [Accepted: 08/25/2017] [Indexed: 02/06/2023]
Abstract
Normothermic ex vivo kidney perfusion (NEVKP) represents a novel approach for graft preservation and functional improvement in kidney transplantation. We investigated whether NEVKP also allows graft quality assessment before transplantation. Kidneys from 30-kg pigs were recovered in a model of heart-beating donation (group A) after 30 minutes (group B) or 60 minutes (group C) (n = 5/group) of warm ischemia. After 8 hours of NEVKP, contralateral kidneys were resected, grafts were autotransplanted, and the pigs were followed for 3 days. After transplantation, renal function measured based on peak serum creatinine differed significantly among groups (P < .05). Throughout NEVKP, intrarenal resistance was lowest in group A and highest in group C (P < .05). intrarenal resistance at the initiation of NEVKP correlated with postoperative renal function (P < .001 at NEVKP hour 1). Markers of acid-base homeostasis (pH, HCO3- , base excess) differed among groups (P < .05) and correlated with posttransplantation renal function (P < .001 for pH at NEVKP hour 1). Similarly, lactate and aspartate aminotransferase were lowest in noninjured grafts versus donation after circulatory death kidneys (P < .05) and correlated with posttransplantation kidney function (P < .001 for lactate at NEVKP hour 1). In conclusion, assessment of perfusion characteristics and clinically available perfusate biomarkers during NEVKP allows the prediction of posttransplantation graft function. Thus, NEVKP might allow decision-making regarding whether grafts are suitable for transplantation.
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Affiliation(s)
- J Moritz Kaths
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.,Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of General, Visceral and Transplantation Surgery, Faculty of Medicine, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Mátyás Hamar
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Juan Echeverri
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Ivan Linares
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Peter Urbanellis
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Jun Yu Cen
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Sujani Ganesh
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Luke S Dingwell
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Paul Yip
- Laboratory Medicine & Pathobiology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Rohan John
- Laboratory Medicine & Pathobiology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Darius Bagli
- Departments of Surgery (Urology) & Physiology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Istvan Mucsi
- Multi Organ Transplant Program, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Anand Ghanekar
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - David Grant
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Lisa A Robinson
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Program in Cell Biology, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Markus Selzner
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
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264
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Schlegel A, Kalisvaart M, Scalera I, Laing RW, Mergental H, Mirza DF, Perera T, Isaac J, Dutkowski P, Muiesan P. The UK DCD Risk Score: A new proposal to define futility in donation-after-circulatory-death liver transplantation. J Hepatol 2018; 68:456-464. [PMID: 29155020 DOI: 10.1016/j.jhep.2017.10.034] [Citation(s) in RCA: 158] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 10/17/2017] [Accepted: 10/25/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Primary non-function and ischaemic cholangiopathy are the most feared complications following donation-after-circulatory-death (DCD) liver transplantation. The aim of this study was to design a new score on risk assessment in liver-transplantation DCD based on donor-and-recipient parameters. METHODS Using the UK national DCD database, a risk analysis was performed in adult recipients of DCD liver grafts in the UK between 2000 and 2015 (n = 1,153). A new risk score was calculated (UK DCD Risk Score) on the basis of a regression analysis. This is validated using the United Network for Organ Sharing database (n = 1,617) and our own DCD liver-transplant database (n = 315). Finally, the new score was compared with two other available prediction systems: the DCD risk scores from the University of California, Los Angeles and King's College Hospital, London. RESULTS The following seven strongest predictors of DCD graft survival were identified: functional donor warm ischaemia, cold ischaemia, recipient model for end-stage liver disease, recipient age, donor age, previous orthotopic liver transplantation, and donor body mass index. A combination of these risk factors (UK DCD risk model) stratified the best recipients in terms of graft survival in the entire UK DCD database, as well as in the United Network for Organ Sharing and in our own DCD population. Importantly, the UK DCD Risk Score significantly predicted graft loss caused by primary non-function or ischaemic cholangiopathy in the futile group (>10 score points). The new prediction model demonstrated a better C statistic of 0.79 compared to the two other available systems (0.71 and 0.64, respectively). CONCLUSIONS The UK DCD Risk Score is a reliable tool to detect high-risk and futile combinations of donor-and-recipient factors in DCD liver transplantation. It is simple to use and offers a great potential for making better decisions on which DCD graft should be rejected or may benefit from functional assessment and further optimization by machine perfusion. LAY SUMMARY In this study, we provide a new prediction model for graft loss in donation-after-circulatory-death (DCD) liver transplantation. Based on UK national data, the new UK DCD Risk Score involves the following seven clinically relevant risk factors: donor age, donor body mass index, functional donor warm ischaemia, cold storage, recipient age, recipient laboratory model for end-stage liver disease, and retransplantation. Three risk classes were defined: low risk (0-5 points), high risk (6-10 points), and futile (>10 points). This new model stratified best in terms of graft survival compared to other available models. Futile combinations (>10 points) achieved an only very limited 1- and 5-year graft survival of 37% and less than 20%, respectively. In contrast, an excellent graft survival has been shown in low-risk combinations (≤5 points). The new model is easy to calculate at the time of liver acceptance. It may help to decide which risk combination will benefit from additional graft treatment, or which DCD liver should be declined for a certain recipient.
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Affiliation(s)
- Andrea Schlegel
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK
| | - Marit Kalisvaart
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK
| | - Irene Scalera
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK
| | - Richard W Laing
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK
| | - Hynek Mergental
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK
| | - Darius F Mirza
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK
| | - Thamara Perera
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK
| | - John Isaac
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK
| | - Philipp Dutkowski
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Zurich, Switzerland
| | - Paolo Muiesan
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK.
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265
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He X, Guo Z, Zhao Q, Ju W, Wang D, Wu L, Yang L, Ji F, Tang Y, Zhang Z, Huang S, Wang L, Zhu Z, Liu K, Zhu Y, Gao Y, Xiong W, Han M, Liao B, Chen M, Ma Y, Zhu X, Huang W, Cai C, Guan X, Li XC, Huang J. The first case of ischemia-free organ transplantation in humans: A proof of concept. Am J Transplant 2018; 18:737-744. [PMID: 29127685 DOI: 10.1111/ajt.14583] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 10/10/2017] [Accepted: 11/02/2017] [Indexed: 01/25/2023]
Abstract
Ischemia and reperfusion injury (IRI) is an inevitable event in conventional organ transplant procedure and is associated with significant mortality and morbidity post-transplantation. We hypothesize that IRI is avoidable if the blood supply for the organ is not stopped, thus resulting in optimal transplant outcomes. Here we described the first case of a novel procedure called ischemia-free organ transplantation (IFOT) for patients with end-stage liver disease. The liver graft with severe macrovesicular steatosis was donated from a 25-year-old man. The recipient was a 51-year-old man with decompensated liver cirrhosis and hepatocellular carcinoma. The graft was procured, preserved, and implanted under continuous normothermic machine perfusion. The recipient did not suffer post-reperfusion syndrome or vasoplegia after revascularization of the allograft. The liver function test and histological study revealed minimal hepatocyte, biliary epithelium and vascular endothelium injury during preservation and post-transplantation. The inflammatory cytokine levels were much lower in IFOT than those in conventional procedure. Key pathways involved in IRI were not activated after allograft revascularization. No rejection, or vascular or biliary complications occurred. The patient was discharged on day 18 post-transplantation. This marks the first case of IFOT in humans, offering opportunities to optimize transplant outcomes and maximize donor organ utilization.
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Affiliation(s)
- Xiaoshun He
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Zhiyong Guo
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Qiang Zhao
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Weiqiang Ju
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Dongping Wang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Linwei Wu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Lu Yang
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Fei Ji
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Yunhua Tang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Zhiheng Zhang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Shanzhou Huang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Linhe Wang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Zebin Zhu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Kunpeng Liu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Yanling Zhu
- Department of Cardiopulmonary Bypass, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yifang Gao
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Wei Xiong
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ming Han
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Bing Liao
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Department of Pathology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Maogen Chen
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Yi Ma
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Xiaofeng Zhu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Wenqi Huang
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Changjie Cai
- Surgical Intensive Care Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiangdong Guan
- Surgical Intensive Care Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xian Chang Li
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China.,Immunobiology and Transplant Science Center Houston Methodist Research Institute, Houston, TX, USA
| | - Jiefu Huang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Peking Union Medical College Hospital, Beijing, China
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266
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Ceresa CDL, Nasralla D, Jassem W. Normothermic Machine Preservation of the Liver: State of the Art. CURRENT TRANSPLANTATION REPORTS 2018; 5:104-110. [PMID: 29564207 PMCID: PMC5843699 DOI: 10.1007/s40472-018-0186-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Purpose of Review This review aims to introduce the concept of normothermic machine perfusion (NMP) and its role in liver transplantation. By discussing results from recent clinical studies and highlighting the potential opportunities provided by this technology, we aim to provide a greater insight into NMP and the role it can play to enhance liver transplantation. Recent Findings NMP has recently been shown to be both safe and feasible in liver transplantation and has also demonstrated its superiority to traditional cold storage in terms of early biochemical liver function. Through the ability to perform a viability assessment during preservation and extend preservation times, it is likely that an increase in organ utilisation will follow. NMP may facilitate the enhanced preservation with improved outcomes from donors after cardiac death and steatotic livers. Furthermore, it provides the exciting potential for liver-directed therapeutic interventions. Summary Evidence to date suggests that NMP facilitates the enhanced preservation of liver grafts with improved early post-transplant outcomes. The key role for this technology is to increase the number and quality of liver grafts available for transplantation and to reduce waiting list deaths.
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Affiliation(s)
- Carlo D L Ceresa
- 1Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - David Nasralla
- 1Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Wayel Jassem
- 2Institute of Liver Studies, King's College Hospital, London, UK
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267
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Ceresa CDL, Nasralla D, Coussios CC, Friend PJ. The case for normothermic machine perfusion in liver transplantation. Liver Transpl 2018; 24:269-275. [PMID: 29272051 DOI: 10.1002/lt.25000] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 12/19/2017] [Indexed: 12/22/2022]
Abstract
In recent years, there has been growing interest in normothermic machine perfusion (NMP) as a preservation method in liver transplantation. In most countries, because of a donor organ shortage, an unacceptable number of patients die while awaiting transplantation. In an attempt to increase the number of donor organs available, transplant teams are implanting a greater number of high-risk livers, including those from donation after circulatory death, older donors, and donors with steatosis. NMP maintains the liver ex vivo on a circuit by providing oxygen and nutrition at 37°C. This permits extended preservation times, the ability to perform liver viability assessment, and the potential for liver-directed therapeutic interventions during preservation. It is hoped that this technology may facilitate the enhanced preservation of marginal livers with improved posttransplant outcomes by reducing ischemia/reperfusion injury. Clinical trials have demonstrated its short-term superiority over cold storage in terms of early biochemical liver function, and it is anticipated that it may result in increased organ utilization, helping to reduce the number of wait-list deaths. However, further studies are required to demonstrate longer-term efficacy and the impact on biliary complications as well as further knowledge to exploit and maximize the potential of this exciting new technology. Liver Transplantation 24 269-275 2018 AASLD.
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Affiliation(s)
- Carlo D L Ceresa
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - David Nasralla
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | | | - Peter J Friend
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
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268
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Liu Q, Nassar A, Buccini L, Iuppa G, Soliman B, Pezzati D, Hassan A, Blum M, Baldwin W, Bennett A, Chavin K, Okamoto T, Uso TD, Fung J, Abu-Elmagd K, Miller C, Quintini C. Lipid metabolism and functional assessment of discarded human livers with steatosis undergoing 24 hours of normothermic machine perfusion. Liver Transpl 2018; 24:233-245. [PMID: 29125712 DOI: 10.1002/lt.24972] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 09/18/2017] [Accepted: 11/05/2017] [Indexed: 02/07/2023]
Abstract
Normothermic machine perfusion (NMP) is an emerging technology to preserve liver allografts more effectively than cold storage (CS). However, little is known about the effect of NMP on steatosis and the markers indicative of hepatic quality during NMP. To address these points, we perfused 10 discarded human livers with oxygenated NMP for 24 hours after 4-6 hours of CS. All livers had a variable degree of steatosis at baseline. The perfusate consisted of packed red blood cells and fresh frozen plasma. Perfusate analysis showed an increase in triglyceride levels from the 1st hour (median, 127 mg/dL; interquartile range [IQR], 95-149 mg/dL) to 24th hour of perfusion (median, 203 mg/dL; IQR, 171-304 mg/dL; P = 0.004), but tissue steatosis did not decrease. Five livers produced a significant amount of bile (≥5 mL/hour) consistently throughout 24 hours of NMP. Lactate in the perfusate cleared to <3 mmol/L in most livers within 4-8 hours of NMP, which was independent of bile production rate. This is the first study to characterize the lipid profile and functional assessment of discarded human livers at 24 hours of NMP. Liver Transplantation 24 233-245 2018 AASLD.
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Affiliation(s)
- Qiang Liu
- Transplantation Center, Cleveland Clinic, Cleveland, OH
| | - Ahmed Nassar
- Transplantation Center, Cleveland Clinic, Cleveland, OH
| | - Laura Buccini
- Transplantation Center, Cleveland Clinic, Cleveland, OH
| | | | - Basem Soliman
- Transplantation Center, Cleveland Clinic, Cleveland, OH
| | | | - Ahmed Hassan
- Transplantation Center, Cleveland Clinic, Cleveland, OH
| | - Matthew Blum
- Transplantation Center, Cleveland Clinic, Cleveland, OH
| | | | - Ana Bennett
- Transplantation Center, Cleveland Clinic, Cleveland, OH
| | - Kenneth Chavin
- University Hospital, Case Western Reserve University, Cleveland, OH
| | | | | | - John Fung
- Transplantation Center, Cleveland Clinic, Cleveland, OH
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269
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Schlegel A, Muller X, Dutkowski P. Hypothermic Machine Preservation of the Liver: State of the Art. CURRENT TRANSPLANTATION REPORTS 2018; 5:93-102. [PMID: 29564206 PMCID: PMC5843682 DOI: 10.1007/s40472-018-0183-z] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW In this review, we highlight which livers may benefit from additional treatment before implantation and describe the concept of hypothermic machine liver perfusion. Furthermore, we explain why cold oxygenated perfusion concepts could potentially lead to a breakthrough in this challenging field of transplantation. Accordingly, we summarize recent clinical applications of different hypothermic perfusion approaches. RECENT FINDINGS The impact of end-ischemic, hypothermic liver perfusion in liver transplantation is currently assessed by two multicenter, randomized controlled trials. Recently, new applications of hypothermic perfusion showed promising results and recipients were protected from severe intrahepatic biliary complications, despite the use of very extended criteria grafts including donation after circulatory death livers. SUMMARY Hypothermic machine liver perfusion is beneficial for high-risk livers and protects recipients from most feared complications. Importantly, such easy approach is currently implemented in several European centers and new markers obtained from perfusate may improve the prediction of liver function in the future.
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Affiliation(s)
- Andrea Schlegel
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK
- NIHR Liver Biomedical Research Unit, University Hospitals Birmingham, Birmingham, UK
| | - Xavier Muller
- Department of Surgery & Transplantation, Swiss HPB and Transplant Center, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - Philipp Dutkowski
- Department of Surgery & Transplantation, Swiss HPB and Transplant Center, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
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270
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Watson CJE, Jochmans I. From "Gut Feeling" to Objectivity: Machine Preservation of the Liver as a Tool to Assess Organ Viability. CURRENT TRANSPLANTATION REPORTS 2018; 5:72-81. [PMID: 29564205 PMCID: PMC5843692 DOI: 10.1007/s40472-018-0178-9] [Citation(s) in RCA: 97] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Purpose of Review The purpose of this review was to summarise how machine perfusion could contribute to viability assessment of donor livers. Recent Findings In both hypothermic and normothermic machine perfusion, perfusate transaminase measurement has allowed pretransplant assessment of hepatocellular damage. Hypothermic perfusion permits transplantation of marginal grafts but as yet has not permitted formal viability assessment. Livers undergoing normothermic perfusion have been investigated using parameters similar to those used to evaluate the liver in vivo. Lactate clearance, glucose evolution and pH regulation during normothermic perfusion seem promising measures of viability. In addition, bile chemistry might inform on cholangiocyte viability and the likelihood of post-transplant cholangiopathy. Summary While the use of machine perfusion technology has the potential to reduce and even remove uncertainty regarding liver graft viability, analysis of large datasets, such as those derived from large multicenter trials of machine perfusion, are needed to provide sufficient information to enable viability parameters to be defined and validated .
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Affiliation(s)
- Christopher J E Watson
- 1Department of Surgery, University of Cambridge School of Clinical Medicine, Cambridge, UK.,2The National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre and the NIHR Blood and Transplant Research Unit (BTRU) at the University of Cambridge in collaboration with Newcastle University and in partnership with NHS Blood and Transplant (NHSBT), Cambridge, UK
| | - Ina Jochmans
- 3Laboratory of Abdominal Transplant Surgery, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium.,4Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium
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271
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272
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Boteon YL, Laing R, Mergental H, Reynolds GM, Mirza DF, Afford SC, Bhogal RH. Mechanisms of autophagy activation in endothelial cell and their targeting during normothermic machine liver perfusion. World J Gastroenterol 2017; 23:8443-8451. [PMID: 29358854 PMCID: PMC5752706 DOI: 10.3748/wjg.v23.i48.8443] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 06/19/2017] [Accepted: 07/12/2017] [Indexed: 02/06/2023] Open
Abstract
Ischaemia-reperfusion injury (IRI) is the leading cause of injury seen in the liver following transplantation. IRI also causes injury following liver surgery and haemodynamic shock. The first cells within the liver to be injured by IRI are the liver sinusoidal endothelial cells (LSEC). Recent evidence suggests that LSEC co-ordinate and regulates the livers response to a variety of injuries. It is becoming increasingly apparent that the cyto-protective cellular process of autophagy is a key regulator of IRI. In particular LSEC autophagy may be an essential gatekeeper to the development of IRI. The recent availability of liver perfusion devices has allowed for the therapeutic targeting of autophagy to reduce IRI. In particular normothermic machine liver perfusion (NMP-L) allow the delivery of pharmacological agents to donor livers whilst maintaining physiological temperature and hepatic flow rates. In this review we summarise the current understanding of endothelial autophagy and how this may be manipulated during NMP-L to reduce liver IRI.
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Affiliation(s)
- Yuri L Boteon
- The Liver Unit, University Hospitals of Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2TT, United Kingdom
- The Centre for Liver Research, Centre for Liver Research, National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute for Biomedical Research, University of Birmingham, Birmingham B15 2TT, United Kingdom
| | - Richard Laing
- The Liver Unit, University Hospitals of Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2TT, United Kingdom
- The Centre for Liver Research, Centre for Liver Research, National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute for Biomedical Research, University of Birmingham, Birmingham B15 2TT, United Kingdom
| | - Hynek Mergental
- The Liver Unit, University Hospitals of Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2TT, United Kingdom
- The Centre for Liver Research, Centre for Liver Research, National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute for Biomedical Research, University of Birmingham, Birmingham B15 2TT, United Kingdom
| | - Gary M Reynolds
- The Centre for Liver Research, Centre for Liver Research, National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute for Biomedical Research, University of Birmingham, Birmingham B15 2TT, United Kingdom
| | - Darius F Mirza
- The Liver Unit, University Hospitals of Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2TT, United Kingdom
- The Centre for Liver Research, Centre for Liver Research, National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute for Biomedical Research, University of Birmingham, Birmingham B15 2TT, United Kingdom
| | - Simon C Afford
- The Centre for Liver Research, Centre for Liver Research, National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute for Biomedical Research, University of Birmingham, Birmingham B15 2TT, United Kingdom
| | - Ricky H Bhogal
- The Liver Unit, University Hospitals of Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2TT, United Kingdom
- The Centre for Liver Research, Centre for Liver Research, National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute for Biomedical Research, University of Birmingham, Birmingham B15 2TT, United Kingdom
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273
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Pezzati D, Ghinolfi D, Balzano E, De Simone P, Coletti L, Roffi N, Rreka E, Meacci L, Campani D, Mazzoni A, Paolicchi A, Caponi L, Marchetti P, Marselli L, Filipponi F. Salvage of an Octogenarian Liver Graft Using Normothermic Perfusion: A Case Report. Transplant Proc 2017; 49:726-728. [PMID: 28457381 DOI: 10.1016/j.transproceed.2017.02.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Liver transplantation with very old donors is safe, but is associated with an increased incidence of ischemic-type biliary lesions and delayed graft function. Normothermic machine perfusion (NMP) is a novel technique for preservation of liver grafts and has the potential to reduce ischemia-reperfusion injury. A case is reported here of a liver transplantation (LT) with a graft from an 83-year-old brain-dead donor. Procurement was with dual perfusion and en bloc, modified fast technique. Donor kidneys were not transplanted due to severe atherosclerosis and poor perfusion. The liver was shipped to the transplantation center and underwent NMP with a blood-based perfusate. During machine perfusion lactates decreased, vascular flow was stable, and bile production restored, and the graft was considered suitable for transplantation. The postoperative course was uneventful and 4 months after surgery the patient is in good clinical condition with normal liver function. To date, few LTs have been performed with NMP in humans, but its preliminary results are promising. NMP allows functional evaluation of the graft and possibly reduction of post-transplantation complications when extended-criteria donor grafts are used.
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Affiliation(s)
- D Pezzati
- Hepatobiliary Surgery and Liver Transplantation Unit, University of Pisa Medical School Hospital, Pisa, Italy
| | - D Ghinolfi
- Hepatobiliary Surgery and Liver Transplantation Unit, University of Pisa Medical School Hospital, Pisa, Italy.
| | - E Balzano
- Hepatobiliary Surgery and Liver Transplantation Unit, University of Pisa Medical School Hospital, Pisa, Italy
| | - P De Simone
- Hepatobiliary Surgery and Liver Transplantation Unit, University of Pisa Medical School Hospital, Pisa, Italy
| | - L Coletti
- Hepatobiliary Surgery and Liver Transplantation Unit, University of Pisa Medical School Hospital, Pisa, Italy
| | - N Roffi
- Hepatobiliary Surgery and Liver Transplantation Unit, University of Pisa Medical School Hospital, Pisa, Italy
| | - E Rreka
- Hepatobiliary Surgery and Liver Transplantation Unit, University of Pisa Medical School Hospital, Pisa, Italy
| | - L Meacci
- Liver Transplant Intensive Care Unit, University of Pisa Medical School Hospital, Pisa, Italy
| | - D Campani
- Division of Pathology, University of Pisa Medical School Hospital, Pisa, Italy
| | - A Mazzoni
- Division of Immunohematology, University of Pisa Medical School Hospital, Pisa, Italy
| | - A Paolicchi
- Translational Research Department, University of Pisa Medical School Hospital, Pisa, Italy
| | - L Caponi
- Translational Research Department, University of Pisa Medical School Hospital, Pisa, Italy
| | - P Marchetti
- Division of Endocrinology and Metabolism in Organ Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - L Marselli
- Division of Endocrinology and Metabolism in Organ Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - F Filipponi
- Hepatobiliary Surgery and Liver Transplantation Unit, University of Pisa Medical School Hospital, Pisa, Italy
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274
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Avruch JH, Bruinsma BG, Weeder PD, Sridharan GV, Porte RJ, Yeh H, Markmann JF, Uygun K. A novel model for ex situ reperfusion of the human liver following subnormothermic machine perfusion. TECHNOLOGY 2017; 5:196-200. [PMID: 31106253 PMCID: PMC6524532 DOI: 10.1142/s2339547817500108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Machine perfusion-based organ preservation techniques are prudently transitioning into clinical practice. Although experimental data is compelling, the outcomes in the highly variable clinical donation-transplantation setting are unpredictable. Here, we offer an intermediate tool for pre-clinical assessment of human donor livers. We present a model for ex situ reperfusion of discarded human livers and report on its application in three human livers that have undergone subnormothermic (21°C) machine perfusion as an experimental preservation method. During reperfusion, the livers macroscopically reperfused in the first 15 minutes, and remained visually well-perfused for 3 hours of ex situ reperfusion. Bile production and oxygen consumption were observed throughout ex situ reperfusion. ATP levels increased 4.25-fold during SNMP. Between the end of SNMP and the end of reperfusion ATP levels dropped 45%. ALT levels in blood increased rapidly in the first 30 minutes and ALT release continued to taper off towards the end of perfusion. Release of CRP, TNF-α, IL-1β, and IL-12, IFN-γ was sustained during reperfusion. These findings support the use of this model for the evaluation of novel human liver preservation techniques.
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Affiliation(s)
- James H Avruch
- Center for Engineering in Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Transplant Center, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Bote G Bruinsma
- Center for Engineering in Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Transplant Center, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Pepijn D Weeder
- Center for Engineering in Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Gautham V Sridharan
- Center for Engineering in Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert J Porte
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Heidi Yeh
- Transplant Center, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - James F Markmann
- Transplant Center, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Korkut Uygun
- Center for Engineering in Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Abstract
PURPOSE OF REVIEW Normothermic machine perfusion of the liver (NMP-L) is a novel technology recently introduced into the practice of liver transplantation. This review recapitulates benefits of normothermic perfusion over conventional static cold storage and summarizes recent publications in this area. RECENT FINDINGS The first clinical trials have demonstrated both safety and feasibility of NMP-L. They have shown that machine perfusion can entirely replace cold storage or be commenced following a period of cold ischaemia. The technology currently allows transplant teams to extend the period of organ preservation for up to 24 h. Results from the first randomized control trial comparing NMP-L with static cold storage will be available soon. One major advantage of NMP-L technology over other parallel technologies is the potential to assess liver function during NMP-L. Several case series have suggested parameters usable for liver viability testing during NMP-L including bile production and clearance of lactic acidosis. NMP-L allows viability testing of high-risk livers. It has shown the potential to increase utilization of donor organs and improve transplant procedure logistics. SUMMARY NMP-L is likely to become an important technology that will improve organ preservation as well as have the potential to improve utilization of extended criteria donor livers.
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278
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Abstract
PURPOSE OF REVIEW The liberalization of donor selection criteria in organ transplantation, with the increased use of suboptimal grafts, has stimulated interest in ischemia-reperfusion injury prevention and graft reconditioning. Organ preservation technologies are changing considerably, mostly through the reintroduction of dynamic machine preservation. Here, we review the current evidence on the role of temperature and oxygenation during dynamic machine preservation. RECENT FINDINGS A large but complex body of evidence exists and comparative studies are few. Oxygenation seems to support an advantageous effect in hypothermic machine preservation and is mandatory in normothermic machine preservation, although in the latter, supraphysiological oxygen tensions should be avoided. High-risk grafts, such as suboptimal organs, may optimally benefit from oxygenated perfusion conditions that support metabolism and activate mechanisms of repair such as subnormothermic machine preservation, controlled oxygenated rewarming, and normothermic machine preservation. For lower risk grafts, oxygenation during hypothermic machine preservation may sufficiently reduce injuries and recharge the cellular energy to secure functional recovery after transplantation. SUMMARY The relationship between temperature and oxygenation in organ preservation is more complex than physiological laws would suggest. Rather than one default perfusion temperature/oxygenation standard, perfusion protocols should be tailored for specific needs of grafts of different quality.
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279
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Cold storage or normothermic perfusion for liver transplantation: probable application and indications. Curr Opin Organ Transplant 2017; 22:300-305. [PMID: 28301388 DOI: 10.1097/mot.0000000000000410] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE OF REVIEW Preservation of the liver via normothermic machine perfusion (NMP) is rapidly becoming an area of great academic and clinical interest. This review focuses on the benefits and limitations of NMP and where the role for static cold storage may lie. RECENT FINDINGS Clinical studies have recently been published reporting the use of NMP in liver preservation for transplantation. They have described the technology to be well tolerated and feasible with potentially improved posttransplant outcomes. NMP facilitates extended preservation times as well as the potential to increase organ utilization through viability assessment and regeneration. However, this technology is considerably more costly than cold storage and carries significant logistical challenges. Cold storage remains the gold standard preservation for standard criteria livers with good long-term patient and graft survival. SUMMARY NMP is an exciting new technological advancement in liver preservation, which is likely to have a positive impact in liver transplantation. However, randomized controlled trials are required to justify its inclusion into standard practice and provide evidence to support its efficacy.
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280
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Role of temperature in reconditioning and evaluation of cold preserved kidney and liver grafts. Curr Opin Organ Transplant 2017; 22:267-273. [PMID: 28266940 PMCID: PMC5617555 DOI: 10.1097/mot.0000000000000402] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Purpose of review Organ shortage in transplantation medicine forces surgical research toward the development of more efficient approaches in organ preservation to enable the application of ‘less than optimal’ grafts. This review summarizes current techniques aiming to recondition cold-stored organ grafts prior to transplantation to reduce reperfusion-induced tissue injury and improve postimplantation graft function. Recent findings End-ischemic reconditioning has classically been attempted by cold oxygenated perfusion. By contrast, evaluation of graft performance prior to transplantation might be facilitated by perfusion at higher temperatures, ideally at normothermia. A drastic temperature shift from cold preservation to warm perfusion, however, has been incriminated to trigger a so-called rewarming injury associated with mitochondrial alterations. A controlled gradual warming up during machine perfusion could enhance the restitution of cellular homeostasis and improve functional outcome upon warm reperfusion. Summary Machine perfusion after conventional cold storage is beneficial for ulterior function after transplantation. Cold grafts should be initially perfused at low temperatures allowing for restitution of cellular homeostasis under protective hypothermic limitation of metabolic turnover. Delayed slow rewarming of the organ might further mitigate rewarming injury upon reperfusion and also increases the predictive power of evaluative measures, taken during pretransplant perfusion.
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Abstract
PURPOSE OF REVIEW Herein, we review the field of subzero organ preservation with a focus on recent developments in hepatic supercooling. RECENT FINDINGS Organ preservation is making a rapid shift from the decade old standard of storage on ice toward techniques that improve organ availability as well as preservation time. Long-term organ preservation would have tremendous benefits to the organ transplantation field, including better organ allocation, donor-recipient matching, as well as reduced preservation injury, and subsequent improvement of donor organ use. The formation of ice has proven an important limiting factor and novel techniques attempt to control or prevent freezing using cryoprotective agents, and highly controlled cooling regimens. Various techniques have been employed over the previous decades, including true organ freezing, vitrification, and subzero nonfreezing or supercooling. For most techniques, successful transplantation following long-term subzero preservation has remained elusive. Supercooling, however, recently delivered the first promising results, yielding survival after up to 4 days of supercooled preservation at -6°C. SUMMARY As the field of organ preservation undergoes significant development, the field of subzero preservation also receives renewed interest. Although many obstacles remain to be overcome to make subzero preservation feasible, novel techniques are beginning to show their potential in achieving long-term preservation.
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282
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Laing RW, Mergental H, Yap C, Kirkham A, Whilku M, Barton D, Curbishley S, Boteon YL, Neil DA, Hübscher SG, Perera MTPR, Muiesan P, Isaac J, Roberts KJ, Cilliers H, Afford SC, Mirza DF. Viability testing and transplantation of marginal livers (VITTAL) using normothermic machine perfusion: study protocol for an open-label, non-randomised, prospective, single-arm trial. BMJ Open 2017; 7:e017733. [PMID: 29183928 PMCID: PMC5719273 DOI: 10.1136/bmjopen-2017-017733] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION The use of marginal or extended criteria donor livers is increasing. These organs carry a greater risk of initial dysfunction and early failure, as well as inferior long-term outcomes. As such, many are rejected due to a perceived risk of use and use varies widely between centres. Ex situ normothermic machine perfusion of the liver (NMP-L) may enable the safe transplantation of organs that meet defined objective criteria denoting their high-risk status and are currently being declined for use by all the UK transplant centres. METHODS AND ANALYSIS Viability testing and transplantation of marginal livers is an open-label, non-randomised, prospective, single-arm trial designed to determine whether currently unused donor livers can be salvaged and safely transplanted with equivalent outcomes in terms of patient survival. The procured rejected livers must meet predefined criteria that objectively denote their marginal condition. The liver is subjected to NMP-L following a period of static cold storage. Organs metabolising lactate to ≤2.5 mmol/L within 4 hours of the perfusion commencing in combination with two or more of the following parameters-bile production, metabolism of glucose, a hepatic arterial flow rate ≥150 mL/min and a portal venous flow rate ≥500 mL/min, a pH ≥7.30 and/or maintain a homogeneous perfusion-will be considered viable and transplanted into a suitable consented recipient. The coprimary outcome measures are the success rate of NMP-L to produce a transplantable organ and 90-day patient post-transplant survival. ETHICS AND DISSEMINATION The protocol was approved by the National Research Ethics Service (London-Dulwich Research Ethics Committee, 16/LO/1056), the Medicines and Healthcare Products Regulatory Agency and is endorsed by the National Health Service Blood and Transplant Research, Innovation and Novel Technologies Advisory Group. The findings of this trial will be disseminated through national and international presentations and peer-reviewed publications. TRIAL REGISTRATION NUMBER NCT02740608; Pre-results.
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Affiliation(s)
- Richard W Laing
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Liver Biomedical Research Unit, National Institute for Health Research (NIHR), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Hynek Mergental
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Liver Biomedical Research Unit, National Institute for Health Research (NIHR), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Christina Yap
- Department of Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Amanda Kirkham
- Department of Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Manpreet Whilku
- Department of Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Darren Barton
- Department of Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Stuart Curbishley
- Department of Liver Biomedical Research Unit, National Institute for Health Research (NIHR), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Yuri L Boteon
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Liver Biomedical Research Unit, National Institute for Health Research (NIHR), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Desley A Neil
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Stefan G Hübscher
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Liver Biomedical Research Unit, National Institute for Health Research (NIHR), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - M Thamara P R Perera
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Liver Biomedical Research Unit, National Institute for Health Research (NIHR), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Paolo Muiesan
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Liver Biomedical Research Unit, National Institute for Health Research (NIHR), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - John Isaac
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Keith J Roberts
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Hentie Cilliers
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Simon C Afford
- Department of Liver Biomedical Research Unit, National Institute for Health Research (NIHR), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Darius F Mirza
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Liver Biomedical Research Unit, National Institute for Health Research (NIHR), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
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Vogel T, Brockmann JG, Pigott D, Neil DAH, Muthusamy ASR, Coussios CC, Friend PJ. Successful transplantation of porcine liver grafts following 48-hour normothermic preservation. PLoS One 2017; 12:e0188494. [PMID: 29176869 PMCID: PMC5703476 DOI: 10.1371/journal.pone.0188494] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 09/30/2017] [Indexed: 12/22/2022] Open
Abstract
Current cold storage organ preservation technique fails to preserve marginal donor grafts sufficiently. Evidence from large animal experiments suggests superiority of normothermic machine preservation of liver allografts. Long-term organ preservation using normothermic perfusion might not only allow organ viability assessment before transplantation, but also provide the means for further organ modifications under physiologic conditions. Previous research has shown that porcine livers can be transplanted successfully after normothermic preservation of 20 hours. In the present study we investigate whether similar methodology is capable of further extending the safe limit to 48 hours. In this study, livers from White Landrace pigs were preserved by normothermic, oxygenated sanguineous perfusion. After a 48-hour period of preservation, livers were transplanted into recipient pigs and followed for 5 days. Outcome parameters measured included markers of synthetic and metabolic liver function as well as hepatocellular injury and blood gas analysis during perfusion and follow-up. Histological assessment of morphological liver integrity was performed. All livers showed sustained bile production and metabolic activity throughout the preservation period. Low levels of hepatocellular damage were found. Following transplantation all liver grafts revealed excellent graft function and death-censored graft survival was 100%. Porcine livers were transplanted successfully following 48 hours normothermic machine preservation.
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Affiliation(s)
- Thomas Vogel
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Jens G. Brockmann
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - David Pigott
- Nuffield Department of Anaesthesia, University of Oxford, Oxford, United Kingdom
| | - Desley A. H. Neil
- Department of Cellular Pathology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | | | | | - Peter J. Friend
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
- * E-mail:
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284
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Ghinolfi D, Rreka E, Pezzati D, Filipponi F, De Simone P. Perfusion machines and hepatocellular carcinoma: a good match between a marginal organ and an advanced disease? Transl Gastroenterol Hepatol 2017; 2:87. [PMID: 29264425 DOI: 10.21037/tgh.2017.10.01] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 09/27/2017] [Indexed: 12/12/2022] Open
Abstract
Hepatocellular carcinoma (HCC) accounts for 90% of primary liver cancers, is the second leading cause of cancer-related deaths and the leading cause of death in patients with cirrhosis. Liver transplantation (LT) represents the ideal treatment for selected patients as it removes both the tumor and the underlying cirrhotic liver with 5-year survival rates higher than 70%. Unfortunately, due to tumor characteristics, patient co-morbidities or shortage of organs available for transplant, only 20% of patients can undergo curative treatment. Ex situ machine perfusion (MP) is a technology recently introduced that might potentially improve organ preservation, allow graft assessment and increase the pool of available organs. The purpose of this review is to provide an update on the current role of ex situ liver MP in liver transplantation for HCC patients.
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Affiliation(s)
- Davide Ghinolfi
- Division of Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Tuscany, Italy
| | - Erion Rreka
- Division of Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Tuscany, Italy
| | - Daniele Pezzati
- Division of Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Tuscany, Italy
| | - Franco Filipponi
- Division of Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Tuscany, Italy
| | - Paolo De Simone
- Division of Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Tuscany, Italy
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The Use of an Acellular Oxygen Carrier in a Human Liver Model of Normothermic Machine Perfusion. Transplantation 2017; 101:2746-2756. [PMID: 28520579 DOI: 10.1097/tp.0000000000001821] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Normothermic machine perfusion of the liver (NMP-L) is a novel technique that preserves liver grafts under near-physiological conditions while maintaining their normal metabolic activity. This process requires an adequate oxygen supply, typically delivered by packed red blood cells (RBC). We present the first experience using an acellular hemoglobin-based oxygen carrier (HBOC) Hemopure in a human model of NMP-L. METHODS Five discarded high-risk human livers were perfused with HBOC-based perfusion fluid and matched to 5 RBC-perfused livers. Perfusion parameters, oxygen extraction, metabolic activity, and histological features were compared during 6 hours of NMP-L. The cytotoxicity of Hemopure was also tested on human hepatic primary cell line cultures using an in vitro model of ischemia reperfusion injury. RESULTS The vascular flow parameters and the perfusate lactate clearance were similar in both groups. The HBOC-perfused livers extracted more oxygen than those perfused with RBCs (O2 extraction ratio 13.75 vs 9.43 % ×10 per gram of tissue, P = 0.001). In vitro exposure to Hemopure did not alter intracellular levels of reactive oxygen species, and there was no increase in apoptosis or necrosis observed in any of the tested cell lines. Histological findings were comparable between groups. There was no evidence of histological damage caused by Hemopure. CONCLUSIONS Hemopure can be used as an alternative oxygen carrier to packed red cells in NMP-L perfusion fluid.
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Sher L, Quintini C, Fayek SA, Abt P, Lo M, Yuk P, Ji L, Groshen S, Case J, Marsh CL. Attitudes and barriers to the use of donation after cardiac death livers: Comparison of a United States transplant center survey to the united network for organ sharing data. Liver Transpl 2017; 23:1372-1383. [PMID: 28834180 DOI: 10.1002/lt.24855] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 08/06/2017] [Indexed: 02/07/2023]
Abstract
Transplantation of liver grafts from donation after cardiac death (DCD) is limited. To identify barriers of DCD liver utilization, all active US liver transplant centers (n = 138) were surveyed, and the responses were compared with the United Network for Organ Sharing (UNOS) data. In total, 74 (54%) centers responded, and diversity in attitudes was observed, with many not using organ and/or recipient prognostic variables defined in prior studies and UNOS data analysis. Most centers (74%) believed lack of a system allowing a timely retransplant is a barrier to utilization. UNOS data demonstrated worse 1- and 5-year patient survival (PS) and graft survival (GS) in DCD (PS, 86% and 64%; GS, 82% and 59%, respectively) versus donation after brain death (DBD) recipients (PS, 90% and 71%; GS, 88% and 69%, respectively). Donor alanine aminotransferase (ALT), recipient Model for End-Stage Liver Disease (MELD), and cold ischemia time (CIT) significantly impacted DCD outcomes to a greater extent than DBD outcomes. At 3 years, relisting and retransplant rates were 7.9% and 4.6% higher in DCD recipients. To optimize outcome, our data support the use of DCD liver grafts with CIT <6-8 hours in patients with MELD ≤ 20. In conclusion, standardization of donor and recipient criteria, defining the impact of ischemic cholangiopathy, addressing donor hospital policies, and developing a strategy for timely retransplant may help to expand the use of these organs. Liver Transplantation 23 1372-1383 2017 AASLD.
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Affiliation(s)
| | - Cristiano Quintini
- Liver Transplantation and HPB Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Sameh Adel Fayek
- Transplant Surgery, Medical City Transplant Institute-Fort Worth, Fort Worth, TX
| | - Peter Abt
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Mary Lo
- Preventive Medicine, Keck School of Medicine of University of Southern California, Los Angeles, CA
| | - Pui Yuk
- Departments of Surgery, Los Angeles, CA
| | - Lingyun Ji
- Preventive Medicine, Keck School of Medicine of University of Southern California, Los Angeles, CA
| | - Susan Groshen
- Preventive Medicine, Keck School of Medicine of University of Southern California, Los Angeles, CA
| | - Jamie Case
- Scripps Center for Organ Transplantation, Scripps Clinic and Green Hospital, La Jolla, CA
| | - Christopher Lee Marsh
- Scripps Center for Organ Transplantation, Scripps Clinic and Green Hospital, La Jolla, CA
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287
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Mergental H, Roll GR. Normothermic machine perfusion of the liver. Clin Liver Dis (Hoboken) 2017; 10:97-99. [PMID: 31186895 PMCID: PMC6499222 DOI: 10.1002/cld.661] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Revised: 08/01/2017] [Accepted: 08/02/2017] [Indexed: 02/04/2023] Open
Affiliation(s)
- Hynek Mergental
- Liver Unit, Queen Elizabeth HospitalUniversity Hospitals Birmingham NHS Foundation TrustBirminghamUnited Kingdom
| | - Garrett R. Roll
- Division of Transplant, Department of SurgeryUniversity of California, San FranciscoSan FranciscoCA
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288
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Chai YC, Dang GX, He HQ, Shi JH, Zhang HK, Zhang RT, Wang B, Hu LS, Lv Y. Hypothermic machine perfusion with metformin-University of Wisconsin solution for ex vivo preservation of standard and marginal liver grafts in a rat model. World J Gastroenterol 2017; 23:7221-7231. [PMID: 29142469 PMCID: PMC5677206 DOI: 10.3748/wjg.v23.i40.7221] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 09/10/2017] [Accepted: 09/19/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To compare the effect of University of Wisconsin (UW) solution with or without metformin, an AMP-activated protein kinase (AMPK) activator, for preserving standard and marginal liver grafts of young and aged rats ex vivo by hypothermic machine perfusion (HMP).
METHODS Eighteen young (4 mo old) and 18 aged (17 mo old) healthy male SD rats were selected and randomly divided into three groups: control group, UW solution perfusion group (UWP), and UW solution with metformin perfusion group (MUWP). Aspartate aminotransferase (AST), alanine aminotransferase (ALT), lactate dehydrogenase (LDH), interleukin-18 (IL-18), and tumor necrosis factor-alpha (TNF-α) in the perfused liquid were tested. The expression levels of AMPK and endothelial nitric oxide synthase (eNOS) in liver sinusoidal endothelial cells were also examined. Additionally, microscopic evaluation of the harvested perfused liver tissue samples was done.
RESULTS AST, ALT, LDH, IL-18 and TNF-α levels in the young and aged liver-perfused liquid were, respectively, significantly lower in the MUWP group than in the UWP group (P < 0.05), but no significant differences were found between the young and aged MUWP groups. Metformin increased the expression of AMPK and eNOS protein levels, and promoted the extracellular release of nitric oxide through activation of the AMPK-eNOS mediated pathway. Histological examination revealed that in the MUWP group, the extent of liver cells and tissue damage was significantly reduced compared with the UWP group.
CONCLUSION The addition of metformin to the UW preservative solution for ex vivo HMP can reduce rat liver injury during cold ischemia, with significant protective effects on livers, especially of aged rats.
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Affiliation(s)
- Yi-Chao Chai
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
- Institute of Advanced Surgical Techniques and Engineering, Regenerative Medicine and Surgery Engineering Research Center of Shaanxi Province, Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Guo-Xin Dang
- Institute of Advanced Surgical Techniques and Engineering, Regenerative Medicine and Surgery Engineering Research Center of Shaanxi Province, Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
- Department of Hepatobiliary and Vascular Surgery, the 521 Hospital of Ordnance Industry, Xi’an 710065, Shaanxi Province, China
| | - Hai-Qi He
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
- Institute of Advanced Surgical Techniques and Engineering, Regenerative Medicine and Surgery Engineering Research Center of Shaanxi Province, Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Jian-Hua Shi
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
- Institute of Advanced Surgical Techniques and Engineering, Regenerative Medicine and Surgery Engineering Research Center of Shaanxi Province, Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Hong-Ke Zhang
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
- Institute of Advanced Surgical Techniques and Engineering, Regenerative Medicine and Surgery Engineering Research Center of Shaanxi Province, Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Rui-Tao Zhang
- Department of Hepatobiliary and Vascular Surgery, the 521 Hospital of Ordnance Industry, Xi’an 710065, Shaanxi Province, China
| | - Bo Wang
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Liang-Shuo Hu
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
- Institute of Advanced Surgical Techniques and Engineering, Regenerative Medicine and Surgery Engineering Research Center of Shaanxi Province, Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Yi Lv
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
- Institute of Advanced Surgical Techniques and Engineering, Regenerative Medicine and Surgery Engineering Research Center of Shaanxi Province, Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
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289
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Kaths JM, Echeverri J, Linares I, Cen JY, Ganesh S, Hamar M, Urbanellis P, Yip P, John R, Bagli D, Mucsi I, Ghanekar A, Grant D, Robinson LA, Selzner M. Normothermic Ex Vivo Kidney Perfusion Following Static Cold Storage-Brief, Intermediate, or Prolonged Perfusion for Optimal Renal Graft Reconditioning? Am J Transplant 2017; 17:2580-2590. [PMID: 28375588 DOI: 10.1111/ajt.14294] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 02/26/2017] [Accepted: 03/26/2017] [Indexed: 01/25/2023]
Abstract
Normothermic ex vivo kidney perfusion (NEVKP) demonstrated superior results compared to hypothermic storage in donation after circulatory death (DCD) kidney transplantation. It is unknown whether an optimal perfusion time exists following hypothermic storage to allow for the recovery of renal grafts from cold ischemic injury. In a porcine model of DCD kidney autotransplantation, the impact of initial static cold storage (SCS) (8 h) followed by various periods of NEVKP recovery was investigated: group A, 8 hSCS only (control); group B, 8 hSCS + 1 hNEVKP (brief NEVKP); group C, 8 hSCS + 8 hNEVKP (intermediate NEVKP); and group D, 8 hSCS + 16 hNEVKP (prolonged NEVKP). All grafts were preserved and transplanted successfully. One animal in group D was sacrificed and excluded by postoperative day 3 due to hind limb paralysis, but demonstrated good renal function. Postoperative graft assessment during 8 days' follow-up demonstrated lowest levels of peak serum creatinine for intermediate (C) and prolonged (D) NEVKP (p = 0.027). Histological assessment on day 8 demonstrated a significant difference in tubular injury (p = 0.001), with highest values for group B. These results suggest that longer periods of NEVKP following SCS are feasible and safe for postponing surgical transplant procedure and superior to brief NEVKP, reducing the damage caused during cold ischemic storage of renal grafts.
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Affiliation(s)
- J M Kaths
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.,Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of General, Visceral, and Transplantation Surgery, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - J Echeverri
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - I Linares
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - J Y Cen
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - S Ganesh
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - M Hamar
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - P Urbanellis
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - P Yip
- Laboratory Medicine & Pathobiology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - R John
- Laboratory Medicine & Pathobiology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - D Bagli
- Departments of Surgery (Urology) & Physiology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - I Mucsi
- Multi Organ Transplant Program, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - A Ghanekar
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - D Grant
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - L A Robinson
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Program in Cell Biology, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - M Selzner
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
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290
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Vining CC, Ecker BL, Abt PL, Olthoff KM. Donation after cardiac death in the hepatocellular carcinoma patient: Same indication? Liver Transpl 2017; 23:S27-S33. [PMID: 28846212 DOI: 10.1002/lt.24862] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 08/14/2017] [Accepted: 08/24/2017] [Indexed: 02/07/2023]
Affiliation(s)
- Charles C Vining
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Brett L Ecker
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Peter L Abt
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Kim M Olthoff
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
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291
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Friend PJ. Advances in normothermic perfusion of the liver. Liver Transpl 2017; 23:S50-S51. [PMID: 28834140 DOI: 10.1002/lt.24854] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 07/27/2017] [Indexed: 02/07/2023]
Affiliation(s)
- Peter J Friend
- Oxford Transplant Center, University of Oxford, Oxford, UK
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292
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Hobeika MJ, Miller CM, Pruett TL, Gifford KA, Locke JE, Cameron AM, Englesbe MJ, Kuhr CS, Magliocca JF, McCune KR, Mekeel KL, Pelletier SJ, Singer AL, Segev DL. PROviding Better ACcess To ORgans: A comprehensive overview of organ-access initiatives from the ASTS PROACTOR Task Force. Am J Transplant 2017; 17:2546-2558. [PMID: 28742951 DOI: 10.1111/ajt.14441] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 06/25/2017] [Accepted: 07/13/2017] [Indexed: 01/25/2023]
Abstract
The American Society of Transplant Surgeons (ASTS) PROviding better Access To Organs (PROACTOR) Task Force was created to inform ongoing ASTS organ access efforts. Task force members were charged with comprehensively cataloguing current organ access activities and organizing them according to stakeholder type. This white paper summarizes the task force findings and makes recommendations for future ASTS organ access initiatives.
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Affiliation(s)
- M J Hobeika
- Department of Surgery, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - C M Miller
- Liver Transplantation Program, Cleveland Clinic, Cleveland, OH, USA
| | - T L Pruett
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - K A Gifford
- American Society of Transplant Surgeons, Arlington, VA, USA
| | - J E Locke
- University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, AL, USA
| | - A M Cameron
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - M J Englesbe
- Department of Surgery, Section of Transplantation, University of Michigan, Ann Arbor, MI, USA
| | - C S Kuhr
- Virginia Mason Medical Center, Seattle, WA, USA
| | - J F Magliocca
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - K R McCune
- Department of Surgery, Columbia University, New York, NY, USA
| | - K L Mekeel
- Division of Transplantation and Hepatobiliary Surgery, University of California San Diego, San Diego, CA, USA
| | - S J Pelletier
- Division of Transplant Surgery, Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - A L Singer
- Transplant Center, Mayo Clinic, Phoenix, AZ, USA
| | - D L Segev
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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293
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Kron P, Schlegel A, Mancina L, Clavien PA, Dutkowski P. Hypothermic oxygenated perfusion (HOPE) for fatty liver grafts in rats and humans. J Hepatol 2017; 68:S0168-8278(17)32268-7. [PMID: 28870676 DOI: 10.1016/j.jhep.2017.08.028] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 08/16/2017] [Accepted: 08/18/2017] [Indexed: 01/06/2023]
Abstract
BACKGROUND & AIMS Pretreatment of marginal organs by perfusion is a promising opportunity to make more organs available for transplantation. Protection of human donation after cardiac death (DCD) livers by a novel machine perfusion technique, hypothermic oxygenated perfusion (HOPE), was recently established. Herein, we tested whether HOPE is also useful for fatty liver grafts, using a rodent transplant model. METHODS Rats were fed over three weeks with a special methionine-choline-deficient diet (MCDD) to induce severe hepatic macrosteatosis (≥60%). Afterwards, livers were transplanted with either minimal or 12h cold storage. Additional liver grafts were treated after 12h cold storage with 1h HOPE before transplantation. Graft injury after orthotopic liver transplantation (OLT) was assessed in terms of oxidative stress, damage-associated molecular patterns release, toll-like receptor-4 activation, cytokine release, endothelial activation, and the development of necrosis and fibrosis. RESULTS Implantation of cold stored macrosteatotic liver grafts induced massive reperfusion injury after OLT, compared to controls (non-fatty livers). HOPE treatment after cold storage failed to change the degree of steatosis itself, but markedly decreased reperfusion injury after OLT, as detected by less oxidative stress, less nuclear injury, less Kupffer- and endothelial cell activation, as well as less fibrosis within one week after OLT. Protective effects were lost in the absence of oxygen in the HOPE perfusate. CONCLUSION HOPE after cold storage of fatty livers prevents significant reperfusion injury and improves graft function, comparable to the effects of HOPE in DCD livers and DCD kidneys. HOPE treatment is easy and may become a universal concept to further expand the donor pool. LAY SUMMARY An increasing number of donor livers contain fat. It is important to harness marginal livers, which may contain fat, as the stock of donor livers is limited. Hypothermic oxygenated perfusion (HOPE) prevents reperfusion injury and improves liver graft function. HOPE offers a simple and low-cost option for treating liver grafts in transplant centers, even after cold storage, instead of transporting machines to the place of procurement. HOPE could be used globally to expand the donor pool.
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Affiliation(s)
- Philipp Kron
- Department of Surgery & Transplantation, University Hospital Zurich, Switzerland
| | - Andrea Schlegel
- Department of Surgery & Transplantation, University Hospital Zurich, Switzerland
| | - Leandro Mancina
- Department of Surgery & Transplantation, University Hospital Zurich, Switzerland
| | - Pierre-Alain Clavien
- Department of Surgery & Transplantation, University Hospital Zurich, Switzerland
| | - Philipp Dutkowski
- Department of Surgery & Transplantation, University Hospital Zurich, Switzerland.
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294
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An Oxygenated and Transportable Machine Perfusion System Fully Rescues Liver Grafts Exposed to Lethal Ischemic Damage in a Pig Model of DCD Liver Transplantation. Transplantation 2017; 101:e205-e213. [PMID: 28403128 DOI: 10.1097/tp.0000000000001764] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Control of warm ischemia (WI) lesions that occur with donation after circulatory death (DCD) would significantly increase the donor pool for liver transplantation. We aimed to determine whether a novel, oxygenated and hypothermic machine perfusion device (HMP Airdrive system) improves the quality of livers derived from DCDs using a large animal model. METHODS Cardiac arrest was induced in female large white pigs by intravenous injection of potassium chloride. After 60 minutes of WI, livers were flushed in situ with histidine-tryptophan-ketoglutarate and subsequently preserved either by simple cold storage (WI-SCS group) or HMP (WI-HMP group) using Belzer-MPS solution. Liver grafts procured from heart-beating donors and preserved by SCS served as controls. After 4 hours of preservation, all livers were transplanted. RESULTS All recipients in WI-SCS group died within 6 hours after transplantation. In contrast, the HMP device fully protected the liver against lethal ischemia/reperfusion injury, allowing 100% survival rate. A postreperfusion syndrome was observed in all animals of the WI-SCS group but none of the control or WI-HMP groups. After reperfusion, HMP-preserved livers functioned better and showed less hepatocellular and endothelial cell injury, in agreement with better-preserved liver histology relative to WI-SCS group. In addition to improved energy metabolism, this protective effect was associated with an attenuation of inflammatory response, oxidative load, endoplasmic reticulum stress, mitochondrial damage, and apoptosis. CONCLUSIONS This study demonstrates for the first time the efficacy of the HMP Airdrive system to protect liver grafts from lethal ischemic damage before transplantation in a clinically relevant DCD model.
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295
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296
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Pezzati D, Hassan A, Buccini L, Liu Q, Diago Uso T, Quintini C. Liver transplantation with geriatric liver allograft in the US: a matter of epidemiology or outcome requirements? Transpl Int 2017; 30:1190-1191. [PMID: 28777472 DOI: 10.1111/tri.13013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Daniele Pezzati
- Cleveland Clinic Lerner College of Medicine, Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ahmed Hassan
- Cleveland Clinic Lerner College of Medicine, Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Laura Buccini
- Cleveland Clinic Lerner College of Medicine, Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Qiang Liu
- Cleveland Clinic Lerner College of Medicine, Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Teresa Diago Uso
- Cleveland Clinic Lerner College of Medicine, Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Cristiano Quintini
- Cleveland Clinic Lerner College of Medicine, Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
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297
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Nickkholgh A, Maluf D. Emerging graft protective strategies in clinical liver transplantation. Expert Rev Gastroenterol Hepatol 2017; 11:623-631. [PMID: 28438069 DOI: 10.1080/17474124.2017.1322901] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
There have been remarkable efforts to characterize the key responsible pathophysiologic mechanisms, as well as to ameliorate the organ preservation and ischemia reperfusion injury with the ultimate goal of expanding the donor pool and further improvement of the outcomes of liver transplantation. Attempts to translate the experimental results from bench to bedside have yielded no valid protective concepts in the field of clinical liver transplantation yet. Nonetheless, there has been a considerable amount of ongoing clinical research to develop clinically relevant graft protective strategies. Areas covered: This review focuses on the most recent evidence based findings and ongoing clinical trials that might lead to emerging graft protective strategies in the field of clinical liver transplantation. New evidence-based findings in the donor preconditioning, organ preservation, and perioperative pharmacologic graft protection strategies in the recipient are reviewed. Expert commentary: Few strategies have been shown to exert some graft protective effects against ischemia reperfusion injury in recent clinical trials in liver transplantation. Among others, 'dynamic graft preservation' techniques have been emerging as more promising graft optimization strategies.
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Affiliation(s)
- Arash Nickkholgh
- a Department of Surgery , University of Virginia , Charlottesville , VA , USA
| | - Daniel Maluf
- a Department of Surgery , University of Virginia , Charlottesville , VA , USA
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298
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Shapiro AMJ. Response to "Normothermic Machine Perfusion: A New World Deserving Careful Exploration". Am J Transplant 2017; 17:1958. [PMID: 28332300 DOI: 10.1111/ajt.14281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- A M J Shapiro
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
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299
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Rahman S, Davidson BR, Mallett SV. Early acute kidney injury after liver transplantation: Predisposing factors and clinical implications. World J Hepatol 2017; 9:823-832. [PMID: 28706581 PMCID: PMC5491405 DOI: 10.4254/wjh.v9.i18.823] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Revised: 03/28/2017] [Accepted: 04/19/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the additional clinical impact of hepatic ischaemia reperfusion injury (HIRI) on patients sustaining acute kidney injury (AKI) following liver transplantation.
METHODS This was a single-centre retrospective study of consecutive adult patients undergoing orthotopic liver transplantation (OLT) between January 2013 and June 2014. Early AKI was identified by measuring serum creatinine at 24 h post OLT (> 1.5 × baseline) or by the use of continuous veno-venous haemofiltration (CVVHF) during the early post-operative period. Patients with and without AKI were compared to identify risk factors associated with this complication. Peak serum aspartate aminotransferase (AST) within 24 h post-OLT was used as a surrogate marker for HIRI and severity was classified as minor (< 1000 IU/L), moderate (1000-5000 IU/L) or severe (> 5000 IU/L). The impact on time to extubation, intensive care length of stay, incidence of chronic renal failure and 90-d mortality were examined firstly for each of the two complications (AKI and HIRI) alone and then as a combined outcome.
RESULTS Out of the 116 patients included in the study, 50% developed AKI, 24% required CVVHF and 70% sustained moderate or severe HIRI. Median peak AST levels were 1248 IU/L and 2059 IU/L in the No AKI and AKI groups respectively (P = 0.0003). Furthermore, peak serum AST was the only consistent predictor of AKI on multivariate analysis P = 0.02. AKI and HIRI were individually associated with a longer time to extubation, increased length of intensive care unit stay and reduced survival. However, the patients who sustained both AKI and moderate or severe HIRI had a longer median time to extubation (P < 0.001) and intensive care length of stay (P = 0.001) than those with either complication alone. Ninety-day survival in the group sustaining both AKI and moderate or severe HIRI was 89%, compared to 100% in the groups with either or neither complication (P = 0.049).
CONCLUSION HIRI has an important role in the development of AKI post-OLT and has a negative impact on patient outcomes, especially when occurring alongside AKI.
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300
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Liver Preservation by Aortic Perfusion Alone Compared With Preservation by Aortic Perfusion and Additional Arterial Ex Situ Back-Table Perfusion With Histidine-Tryptophan-Ketoglutarate Solution: A Prospective, Randomized, Controlled, Multicenter Study. Transplant Direct 2017; 3:e183. [PMID: 28706986 PMCID: PMC5498024 DOI: 10.1097/txd.0000000000000686] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 04/03/2017] [Indexed: 12/14/2022] Open
Abstract
Background Arterial ex situ back-table perfusion (BP) reportedly reduces ischemic-type biliary lesion after liver transplantation. We aimed to verify these findings in a prospective investigation. Methods Our prospective, randomized, controlled, multicenter study involved livers retrieved from patients in 2 German regions, and compared the outcomes of standard aortic perfusion to those of aortic perfusion combined with arterial ex situ BP. The primary endpoint was the incidence of ischemic-type biliary lesions over a follow-up of 2 years after liver transplantation, whereas secondary endpoints included 2-year graft survival, initial graft damage as reflected by transaminase levels, and functional biliary parameters at 6 months after transplantation. Results A total of 75 livers preserved via standard aortic perfusion and 75 preserved via standard aortic perfusion plus arterial BP were treated using a standardized protocol. The incidence of clinically apparent biliary lesions after liver transplantation (n = 9 for both groups; P = 0.947), the 2-year graft survival rate (standard aortic perfusion, 74%; standard aortic perfusion plus arterial BP, 68%; P = 0.34), and incidence of initial graft injury did not differ between the 2 perfusion modes. Although 33 of the 77 patients with cholangiography workups exhibited injured bile ducts, only 10 had clinical symptoms. Conclusions Contrary to previous findings, the present study indicated that additional ex situ BP did not prevent ischemic-type biliary lesions or ischemia-reperfusion injury after liver transplantation. Moreover, there was considerable discrepancy between cholangiography findings regarding bile duct changes and clinically apparent cholangiopathy after transplantation, which should be considered when assessing ischemic-type biliary lesions.
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